Scalp psoriasis: treatment, symptoms and everyday scalp care

The Psoriasis Association says some shampoo treatments can be bought over the counter, but if your scalp is covered with thick scale or does not clear up you should consult your GP. A wide range of topical treatments can be prescribed, including coal tar, dithranol, salicylic acid, steroid creams and ointments, vitamin D-based treatments, and oils such as coconut oil for moisturising the scalp. They come as creams, ointments, mousses, gels or shampoos.

The BAD topical treatment leaflet explains the roles. Topical corticosteroids reduce inflammation and come in mild, moderate, potent and very potent strengths. If potent or very potent steroids are used on the same area for many months or years there is a small risk of skin thinning, so ongoing prescriptions should be monitored. Vitamin D-like chemicals such as calcipotriol are described as safe and popular because they do not stain or have a strong odour, though they are not usually prescribed during pregnancy and breastfeeding and can irritate sensitive areas. Many products combine a steroid with a vitamin D-like chemical or salicylic acid.

Salicylic acid reduces scaling on thick areas, and tar preparations reduce the thickness of the psoriasis but have a distinctive smell and can stain clothing. BAD says dithranol is useful for stubborn areas of psoriasis on non-delicate skin, is usually given as short-contact therapy at home, and is increasingly difficult to get hold of. Emollients help soften scale and are best applied about 30 minutes before other treatments. Oil-based preparations on skin, hair and clothes can catch fire, so avoid smoking and naked flames.

If scalp psoriasis is particularly difficult to treat, the Psoriasis Association says your GP may refer you to a dermatologist, a dermatology nurse specialist or a GP with a special interest in skin. BAD says psoriasis covering large areas may need other treatments such as light therapy, tablets or injections. The NHS adds that the treatment depends on the type of psoriasis, how severe it is and where it is on the body, and that a combination of treatments may be needed.

Psoriasis is a common skin condition that causes itchy, sore, flaky patches. The NHS says it cannot be cured but treatments help manage symptoms, and the British Association of Dermatologists (BAD) describes it as affecting about 1 in 50 people, tending to come and go unpredictably, and not being infectious. When the patches appear on the scalp the Psoriasis Association calls it scalp psoriasis, noting that the scalp is one of the most common places for plaque psoriasis and is often the first area affected.

It may involve only part of the scalp or the whole of it, and can extend beyond the hairline onto the forehead, neck and behind the ears. The NHS lists the head and behind the ears among the most common sites for psoriasis in general. BAD notes that psoriasis does not scar the skin, although it can cause short-term lightening or darkening of skin colour.

Scalp psoriasis appears as raised, red patches of skin covered with silvery, white or yellow scales, which on darker skin tones may look darker than the surrounding skin. Loose scale can look like dandruff and may be noticeable in the hair or on dark clothing. The scalp can also feel itchy and tight. Some people with severe scalp psoriasis or very thick scaling notice temporary thinning of the hair, often because of scale build-up or scratching, which the Psoriasis Association says should regrow once the psoriasis has subsided.

The NHS dandruff page explains how to separate possible causes. Dandruff causes white flakes and a dry, itchy scalp. Red, flaky, crusty and sore patches covered with silvery scales point towards psoriasis, scaly itchy red patches on the scalp and face suggest seborrhoeic dermatitis, and a red or silvery rash with patchy hair loss can be ringworm of the scalp. If dandruff shampoo has not helped after at least 4 weeks, the NHS says to see a GP.

• Well-defined thick, scaly plaques rather than fine, loose flakes.

• Patches that extend past the hairline onto the forehead, neck or behind the ears.

• Itching and tightness, sometimes with soreness.

• Possible psoriasis elsewhere, such as elbows, knees or nails.

The NHS says psoriasis is caused by the skin making more skin cells than usual, which creates patches on the skin. It is not known why or how this happens, but it is thought to be caused by a problem with the immune system. You are more likely to have it if a member of your family has psoriasis.

The NHS lists triggers that can make psoriasis worse or cause a flare-up: stress, drinking alcohol or smoking, living with obesity, being pregnant, certain medicines, infections such as strep A and HIV, and cuts and scratches. BAD says psoriasis can appear at any age, in any skin type, and tends to come and go unpredictably.

The Psoriasis Association stresses getting the method right: treatment needs to be on the scalp rather than the hair, so it may be best to part the hair in sections and apply to the exposed scalp, perhaps with help to reach the back and top. Some products are left on and some washed out after a set time, so follow the instructions or the advice of your doctor, nurse or pharmacist. BAD adds that shampoos should be massaged into the scalp and left on as instructed before rinsing.

Practical tips from the charity include brushing and combing hair gently and regularly, which can help remove loose scale, softening plaques with moisturiser or an oil such as olive or coconut oil and lifting them rather than picking, protecting pillowcases during treatment, giving each treatment weeks rather than days to work, and telling your GP or dermatologist if a treatment causes problems. Highlights that do not touch the scalp should be fine, while perms and dyes usually need a patch test and are not advisable if the skin is broken.

The NHS says to see a GP if you have symptoms of psoriasis, if your treatment is not working or is giving you side effects, or if you also have pain, stiffness and swelling in your joints that keeps coming back. If dandruff shampoo has not helped after at least 4 weeks, the NHS dandruff page also says to see a GP.

The NHS says to call 999 or go to A&E if you have psoriasis and your skin quickly turns red and you develop white, pus-filled bumps that join together, if patches on your feet turn yellow-brown and are filled with pus, or if your fingers and toes have red, scaly pus-filled bumps on the tips. These can be signs of a more serious condition or an infection. Do not drive yourself to A&E.

Psoriasis tends to come and go. The Psoriasis Association says that after treatment some people have no further flare, while others have periods clear of scalp psoriasis followed by a return. BAD says there is no cure yet and psoriasis can come back if treatment is stopped, but that it can often be improved or cleared by regular treatment.

BAD also notes that psoriasis can affect the nails and joints, and that for people with moderate to severe psoriasis about one in three will develop psoriatic arthritis at some time. Joint pain or stiffness, particularly in the morning, should be mentioned to your GP.

The NHS route starts with a pharmacist or GP and can progress to dermatology if topical treatments fail. Private dermatologists can offer quicker access, reviews of long-term steroid use, and specialist treatments such as light therapy or systemic medicines where appropriate, but the first-line topical principles are the same. Ask for a written plan that lists each product, where it goes, how long to leave it on and how often it should be used.